25 April 2010

In the annals of "things you probably wished you hadn't said," Sue Lowden, the Republican candidate to replace Nevada Senator Harry Reid, suggested last week that bartering for medical care was a workable substitute for the Affordable Care Act, which she is campaigning to repeal.

Surprisingly, after being called out and roundly mocked for the suggestion, she doubled down on the idea: "You know, before we all started having health care, in the olden days, our grandparents, they would bring a chicken to the doctor. They would say I'll paint your house."

I know that it's hardly fair to pile on someone running for office for a bit of stump-speech dumbassery, but it just needs to be said. As much as I enjoy a nice chicken sandwich from time to time, barter is not a feasible mode of payment for services any more. A doctor can't pay his staff, his rent, or his malpractice insurance in chickens.

A related suggestion was the idea of patients negotiating the price for services directly with their doctors. This also fails the giggle test on a number of levels. First of all, that is one of the advantages of belonging to an insurance program -- they do the negotiating for you, and because of their size they command much deeper discounts than any individual ever could. This assumes that a doctor even cares to discuss price with an individual patient. In the ER I never do, not only because of the circumstances, but because I honestly don't know in advance exactly which of the thousands of codes (and prices) a given patient interaction will result in.

Moreover, without the protection of insurance, the likelihood that any private individual will be able to afford the cost of an ER visit, let alone a surgery or hospitalization is essentially nil.

It's depressing to realize that there's a substantial likelihood that this dimwit will be the next Senator from Nevada.

When Sue Lowden headed the Santa Fe hotel-casino, management forced a group of workers to shift to part-time status and sign away their health care coverage, said a judge who ruled the company violated fair labor practices.

4 comments:

The barter thing is ridiculous, but I'm somewhat in favor of individual payment/negotiation for routine care (not emergency services, obviously). I used to see my PCP on a cash-payment basis and it worked out pretty well...I've probably had balance-bills for 15 minutes of an NP's time (and a disposable speculum) that cost me more than I paid my former PCP up-front for a real appointment. The down side unfortunately is that pulling low-cost patients like me out of the insurance pool and letting us go to out-of-pocket routine care with catastrophic/hospital insurance only is bad for the pool as a whole.

I am not sure this dimwit will be any worse than the current one in that seat.

But I have to take issue with you on your belief that empowering patients to become better medical consumers will not drive down health care costs. Real world data doesn't seem to support that argument.

Now, EDs are not exactly the place where you would expect market forces to be beneficial, nor is OR, which is why I think your examples are somewhat irrelevant. We definitely should have insurance for such catastrophic events as ED/OR visits. That's really what 'insurance' is...a bet on the chance that one might have a heart attack, or cancer, or appendicitis.

However, I would argue that routine primary care activities could use a health dose of market forces and more consumer skepticism. For example, I am an allergist. As such, I know that I would like to offer a number of services that my patients that might give them (and me) more info on their condition. But I am under no illusion that most of what I offer is absolutely medically-necessary. Why check five tree pollen skin tests when I can do one tree mix test? Yes, the added info is helpful, but is it worth the cost? I wrestle with these kind of decisions everyday. I also find that my patients often will say 'more is better,' especially if the insurance company is paying for it. If they paid for it, they would be more discerning on what really important to them.

Furthermore, your argument that insurance companies are advocates FOR patients doesn't really hold. They are, more often than not, acting at limiting access to care rather than effectively or compassionately negotiating for patients, most of whom don't pay for their insurance but get it through the real payers....their employers. Needless to say, all of these third parties lead to a rather skewed interaction where the patient is often left out of the loop.

If a patient has say, a consumer-driven health care plan (CDH) that operates both as true insurance (covering catastrophic issues) and allows the patients to control and guide his/her own routine health care dollars, then costs can be driven down.

For example, a study released last year by the American Academy of Actuaries proved as much.

The AAA showed CDHs decrease costs an average of 12-21% over traditional insurance plans. Introducing true market pressure into an industry where doctors like yourself self-admittedly don't even understand the true costs of their work can only help save patients money.

But you may retort that patients would then neglect primary care with such market pressures. Interestingly, that's not the case. The same study found that when patients took a greater role in their health care decision making, and were able to affect its cost, they underwent 'needed' screening. Furthermore, the care they received also tended to conform better to evidence-based standards than did the care they received under traditional insurance. When push comes to shove, patients learn what is important and extract the maximal amount of value in the patient-physician interaction.

Now on to the point that started me reading your article-bartering. I have on occasion taken bartered items from my patients in exchange for my services. That's easier to do as a physician working in a private practice rather then your experience as, essentially, an employee of a hospital emergency department.

While one cannot completely run a business through bartering alone, in some circumstances it has allowed my patients to get care they need while I have been able to be reimbursed for my labor. Accordingly, I wouldn't mock such interactions as they really connect me and my patients in relationships that I have found much more meaningful that waiting for a check from Aetna.

Patients negotiate the prices for boob jobs and Lasik all the time. That's why doctors advertise those prices on the radio.

And lo and behold, those are two medical procedures that have fallen substantially in price while most every other procedure has gone up dramatically in price in the last decade.

Behold the power of the consumer chasing a bargain. Shadowfax, have you cut prices by 90% in the last decade, while at the same time brought your patients the latest technology? The guy I hear on the radio offering me Lasik has.

PS. Palin was right. Death panels are coming. Government decides what treatment you get. Not doctors. UK QALY will soon be here.

This is actual payout before income tax deductions or costsNote that the highest payout is at least $1.3 million....some of the lower numbers are PT or new MDs.There is controversty on the payment per treatment due to the fact that GPs out number each specialty so they may lobby for more pay for something a specialist does....eg. a "complicated delivery" or "anesthesia"

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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